R-5635 PERMIT R- 5635 .
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
,AADDDRESS
av Tr L t �I Ca A.c RESIDENTIAL COMMERCIAL OTHER
OWNER'S 1 1 r r � HAZARDOUS FIRE AREA
YES 'SH yes—I understand that a Class A
NAME ' �'C t ' root assembly is required.
4 N Initial I.C.B.O.k
ADDRESS ✓ Oil m e-0- EXISTING ROOF COVERING
PHONE g 6 NUMBER OF EXISTING COVERINGS
CONTRACTO 'S e
NAME C>Ll [ S eitO
f TO BE REMOVED 4 TO BE RETAINED
ADDRESS � /
TYPE OF ROOF COVERING
CITY&ZIP !�r �r / O Lq
:-I ,, Pt e-0, C, 5'0 .L EXISTING
• PHONE /4 aR! - !5-4
GiL4 L BUILT-UP ROOF ❑
LICENSE G (D ASPHALT SHINGLES ❑ �S� J
NUMBER ' ✓
LICENSED CONTRACTORS DECLARATION �e
I hereby iaffirmnion that em licensed under Professions
lone of e,and 9(commencing with Section WOOD SHAKES
]000)of Division 3 of the Business and Professlons Code,end my license Is In full brce and
effect.
CWOOD SHINGLES ❑
License Class C Lic.Number
Date contractor)% n 14 1 OTHER (SPECIFY) ❑
R-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law(Chapter 9(commencing with Section]000)of Division 3 of the
. Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles-
slons Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑ g
Improves thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intended or offered for sale.If,however,the building or Improvement
Is Sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑1\1" ) O W I (�
not build or Improve for purpose of sale.).
I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sac.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon.and who contracts for such projects
with a contractogs)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
F7 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPWCLTPKDATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 hereby affirm untler penalty of perjury one of the following declaration: T
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Buil�l}�lg
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this APR 1 RECD tt\TT71 `
permit is Issued. }� Sets IC
01 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of `1
_the Labor Code,for the performance of the work for which this permit is Issued.My Worker's
Compensation Insurance carrier entl Policy numb re: 1 n ) _�7Y OF CUPEH f INO � Total
Carrier 5: Policy No. 612,, G PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N
(This section need not be completed If the permit Is for one hundred dollars($100)00)o or lase.) �'�■1 {/7s�`)i_
I certify that In the performance of the work for which this permit Is issued, shell not employ .
any person any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtainingan
Data;Zyl g � Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO AP (CANT: It,after making this Certificate of Exemption,you should become Applicant understand with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P
with such provisions or this permit shalgbe deemed revoked. Source regulations
I certify that I have read this application and state that the above Information Is correct I agree
to comply with all city and county ordinances and state laws relating to building construction,entl All roof coverings obe class r ar.kZ�
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against sold City In consequence
othe granting ofthis permit. SIGNATURE OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
• SUBJECT: REROOFu1G POLICY FOR THE CITY OF CUPERTNO BUILDIIN�G DEPART`FENT
PRIOR TO ISSUANICE OF PERMIT AND NSPECTION MASE.
, you mus; agree to compiv with U.B.C. standards and manufac,
1. Prior to per ni[ issuancesea sec's
on re:cofing.
2. New roof coverings shall not be applied without first ob[aining all inspection and nT ,ea approval
from the building inspector. A final inspection and approval shall be obtained from the building
insmector when the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final,you must complete steps.1,2,and 3.
i
1,) Preinspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke detr_'tor verification
• b.) Spark arrestor installation
5. If plywood is installed,a plywood nail inspection is required.
6. If any roof is applied without first obtaining an inspection, you will be required to remove all new
material down io the sheathing and a building inspector will inspect all sheathing at that time.
E UNDERSTANfD THE ABOVE POLICY ON REROOFFNG P_ND WILL COMPLY WITH TrE
W
POLICY
HO vtEOWNcRS N 12
AME: �h
ADDRESS;
REROOF u iG COMPANY NAME: O L4t w c, y
i t
APPLICA.N7S SIGNATURE:
CITY OF CUPERTNO
BUILDNG DEPARTMENT
•
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